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For plans that contain pharmacy coverage. Check the applicable benefits design or the certificate of insurance for more information.
ConsumerDirect PPO (2 - 50)
EmblemHealth high deductible health plans (HDHPs) feature lower premiums based on a higher than usual annual deductible and offers a separate Health Savings account that members own and can use for future medical expenses with tax-free dollars.
Plan Overview
Choice
We respect that different people have different needs. That's why we offer a choice of affordable, quality plans with extensive benefits that provide real value:
Four plans to choose from and a selection of deductibles to meet member needs.
Affordability
Members pay no out-of-pocket costs for covered in-network preventive care, including routine physicals, screenings, immunizations, mammograms, gynecological exams, well-baby care and more. These services are not subject to the plan's annual deductible. 1
Low network pharmacy copay $0 for generic, $20 for preferred, and $40 for non-preferred prescription drugs after the plan's annual deductible is met.
Triple tax savings . Membercontributions to HSA s are tax free, withdrawals for qualified medical expenses are tax free, and the money saved in the account earns interest tax free. Members may contribute up to the amount of their deductible. Any money not used in a given year rolls over to the next year.
Quality
Quality doctors. Our National network includes more than half the "Top Docs" from New York Magazine's list, and virtually every acute care hospital in the region—great hospitals like Memorial Sloan-Kettering, Montefiore Medical Center, Lenox Hill Hospital, North Shore- Long Island Jewish Health System, and Albany Medical Center.
Health and Wellness Programs. We help members stay healthy with*:
Timely reminders about flu shots and diagnostic testing, such as mammograms and prostate exams.
Quit-smoking programs.
A Nurse Advice Line that members may call 24/7 to speak with a Registered Nurse.
Discounts on health-related services such as weight-loss programs, laser vision, and acupuncture.2
Confidential, professional counseling, education, and referral services through our 24/7 toll-free Employee Assistance Program (EAP) hotline.
Access to Care
Our National network provides access regionally to more than 106,000 doctors at more than 172,000 locations in New York, New Jersey, and Connecticut and to more than one million practitioners nationwide.
Ease
Less paperwork. With EmblemHealth ConsumerDirect PPO, there are generally no claim forms to file for services received in-network.
24/7 customer service. Easy-to-use online tools, available at our secure web site, www.emblemhealth.com, make it easy for members to manage their account activity, balances, and savings growth. In addition, members may access provider listings, eligibility, claims status, benefits, and more online or by calling our automated phone system.
Respect
At EmblemHealth, we understand the things that matter to members about their health care coverage—including respect for their time, intelligence, and money.
Plan Details
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| Services | in-network | out-of-network |
|---|---|---|
| Office Visit | Deductible & Coinsurance | Deductible & Coinsurance |
| Annual Physical Check-up | Covered in Full | Deductible & Coinsurance |
| Preventive Mammography, Pap Smear, Prostate Screening | Covered in Full | Deductible & Coinsurance |
| Well-Baby and Well-Child Care | Covered in Full | Deductible & Coinsurance |
| Inpatient Hospital Services | Deductible & Coinsurance | Deductible & Coinsurance |
| Skilled Nursing Facility Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Hospice Care - Inpatient and Outpatient | Deductible & Coinsurance | Covered In-Network Only |
| Ambulatory Surgery Facility | Deductible & Coinsurance | Deductible & Coinsurance |
| Home Health Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Chiropractic Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Diagnostic Lab and Radiology | Deductible & Coinsurance | Deductible & Coinsurance |
| Emergency Room Facility | Deductible & Coinsurance | Deductible & Coinsurance |
| Inpatient Mental Health Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Outpatient Mental Health Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Inpatient Chemical Dependency Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Outpatient Chemical Dependency Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Prescription Drugs | Deductible & Coinsurance | Covered In-Network Only |
1 Some services are subject to precertification.
2 EmblemHealth cannot ensure that a particular vendor will remain in the program. The services available under these programs are not covered services underwritten by Group Health Incorporated ("GHI") as part of the EmblemHealth ConsumerDirect PPO.
* Availability of health and wellness programs may vary based on the EmblemHealth product selected.
Please note: If members choose non-network providers, their out-of-pocket costs will increase.
The EmblemHealth ConsumerDirect PPO program is underwritten by Group Health Incorporated ("GHI"). Coverage is subject to all terms, conditions, limitations, and exclusions set forth in the contract and certificate of insurance. Refer to GHI policy form numbers PLH-SGC - 1000, et. al.
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